Caregivers' knowledge, practice, and associated factors toward oral rehydration salt with zinc to treat diarrhea among under 5 children in Burayu town, Oromia, Ethiopia, 2022: Cross‐sectional study: An implication for action

Abstract Background Diarrhea is the second leading cause of death in under 5 children of Ethiopia. Millions of young lives could be saved if mothers know and practice the three rules of diarrhea management: giving extra fluid (particularly oral rehydration salt [ORS]), zinc, and giving additional food during diarrhea illness. Aim The objective of this study was to determine mothers'/caregivers' Knowledge, Practice, and associated factors toward ORS with zinc to treat diarrhea among under 5 children in Burayu town, Oromia Region, Ethiopia, 2022. Methods A community‐based cross‐sectional study was conducted among 422 study participants from September 25 to October 10, 2022; in Burayu town, Ethiopia. Systematic random sampling technique was used to enroll study subjects from two randomly selected kebeles. Interviewer‐administered structured questionnaire was used to collect data. Data were entered into Epi‐info version 3.5.1 and exported to SPSS Version 21 for analysis. Binary and multivariable logistic regression was done to identify factors associated with knowledge and practice of ORS with zinc at p < 0.05% and 95% confidence interval (CI). Results The findings showed that 59% and 52% of the respondents had good knowledge and practice toward ORS with zinc, respectively. Being housewives (adjusted odds ratio, AOR = 0.407, 95% CI: [0.195, 0.848]), primary education (AOR = 3.246, 95% CI: [1.614, 6.530]), income of >4000 (AOR = 5.132, 95% CI: [1.947, 13.524]), health seeking behavior (AOR = 0.369, 95% CI: [0.139, 0.979]), being divorced (AOR = 0.275, 95% CI: [0.09,0.842]) were found to be significantly associated with knowledge toward management of diarrhea with ORS and zinc. Housewives in occupation (AOR = 0.084, 95% CI: [0.029, 0.243]), secondary and above education (AOR = 6.26: 95% CI: [1.51, 25.86]), health seeking behavior (AOR = 6.885, 95% CI: [2.29, 20.67]), having good knowledge of ORS and zinc (AOR = 22.14, 95% CI: [8.44, 58.07]) were found to be significantly associated with practice of managing diarrhea with ORS and zinc. Conclusion This study revealed low level of knowledge and practice of caregivers toward ORS with zinc. The more mothers/caregivers are knowledgeable, the more they are active to practice the use of ORS with zinc. Thus, health education and awareness creation for the mothers/caregivers on management of diarrhea is very crucial. Special attention should be given to enhancing income for mothers/caregivers.


| BACKGROUND
World Health Organization (WHO) defines diarrhea as the passage of three or more loose or watery stools in 24-h duration. 1Diarrhea is still among the major causes of mortality among children under 5 years of age; by making the second leading cause of death.About 437,000 of under 5 children are dying of diarrhea each year worldwide. 2Majority of these deaths are as result of dehydration and mismanagement.
Diarrhea is both preventable and treatable disease, but due to improper knowledge of mothers and their misdirected approach toward the disease management results in severe dehydration and death. 3e goals of diarrhea treatment are to maintain or recover hydration, treat the underlying causes, and relieve symptoms.The use of oral rehydration salt (ORS) is extremely effective in treating acute watery diarrhea and has markedly contributed to reducing childhood deaths.Currently, many diarrhea-associated deaths could be prevented by timely treatment with ORS. 4 Timely management of children with ORS and zinc has substantially declined the mortality and morbidity from acute diarrhea.
Giving ORS after each loose stool until diarrhea stops and supplementing zinc for 10-14 days are safe and effective in both home and facility settings when properly prepared and administered.6][7][8] In addition, there is knowledge gap among health care providers about zinc supplementation for diarrheal treatment. 9More than 60% of childhood diarrhea could be prevented with full coverage of ORS and zinc. 1 Yet, of those children with acute diarrhea, only a median of 42% receive ORS and less than 7% receive both ORS and zinc globally. 10Zinc supplements reduce the duration of diarrheal episodes by 25% and reduce stool volume by 30%. 1,5,11It is also a vital micronutrient essential for protein synthesis, cell growth and differentiation, immune function, and intestinal transport of water and electrolytes. 12ildhood diarrhea accounts for 10% of all causes of morbidity in under 5 children of Ethiopia and it is the second leading cause of deaths, after pneumonia. 13,14More than three-quarters of all diarrhea deaths could be averted with full coverage and utilization of ORS and zinc supplementation. 15hiopia has been using different strategies and has made many efforts to reduce diarrhea related morbidity and mortality.Integrated Management of Childhood Illness is one of the strategies which focuses on the management of the top 5 diseases among under 5 children including diarrhea.Accordingly, every child with diarrhea should be treated with ORS and zinc. 16wever, utilization of ORS and zinc is influenced by many factors such as caregivers' sociodemographic status, socioeconomic status, previous experience, and other factors.[19][20] On the other hand, research on the knowledge and practice toward zinc and ORS among mothers' of children with diarrheal diseases is scarce in Ethiopia.To assess the success of zinc supplementation along with ORS in diarrheal diseases management, and to find ways of promoting it, a study on caregivers' knowledge and practice toward zinc with ORS and associated factors to treat children with diarrhea was needed.Therefore, in this study knowledge, practice, and associated factors toward ORS with zinc among mothers/caregivers of under 5 children were assessed.

| Study area and period
The study was conducted in Burayu town.Burayu town is located in the western fringe of Addis Ababa the Capital city of Ethiopia.
The town has 375,349 total populations, about 50,513 households (HHs) and 61,670 under 5 children. 21Due to this demographic pressure water scarcity is common in the town.
The current water supply coverage of the city is 60% which can contribute to diarrheal diseases in the town.Burayu town has six kebeles.The town has four health centers, 51 medium clinics, two small clinics, 11 pharmacies, 44 drug stores, and six health posts. 22e study was conducted from September 25 to October 10, 2022.

| Study design
A community-based cross-sectional study was conducted in Burayu town.

| Population
Source population: All mothers/caregivers having under 5 children and living in Burayu town.

| Study population
All mothers/caregivers having under 5 children in randomly selected kebeles, in Burayu town.

| Sampling unit
HHs having under 5 children.

| Study unit
Care giver/mother having children younger than 5 years.

| Inclusion criteria
Mothers/caregivers who have under 5 children and have willing to participate in the study in selected sub kebeles during the study period.

| Exclusion criteria
None of the mothers/caregivers under sampling plan were not fulfilled the exclusion criteria.

| Sample size determination and sampling technique
The sample size was determined by using a single population proportion formula with the following assumptions; estimation of the proportion of knowledge of ORS with zinc in the study area as 50%, 95% confidence interval (CI), 5% margin of error (d), and 10% nonresponse rate.
where z is the standard normal distribution (

| Sampling technique
The list of registrations of HHs who had under 5 children was taken from local health extension workers of the kebeles; two kebeles were selected randomly from six kebeles in Burayu town.Accordingly, the total number of HHs who had under 5 children in the two selected kebeles were 6121.The number of mothers who have under 5 children was selected from the two kebeles (Gafersa Guje and Gafersa Nono) based on the population proportion size of the study population.Study HHs were selected by systematic random sampling method every 15 (Figure 1).

| Dependent variable
Knowledge of mothers/caregivers toward ORS with zinc supplementation.
Practice of mothers/caregivers toward ORS with zinc supplementation.

Sociodemographic status
Age of respondent, sex of respondent, marital status, educational status, religion, ethnicity, occupation, Relation of caregivers to a child, income.

Maternal related factors
Mothers'/caregivers' health seeking behavior, place sought for treatment/type of health facility visited, previous experience (ever experienced child with diarrhea).

Health facility-related factors
Availability of ORS with zinc, price of ORS with zinc.

| Poor knowledge
Those mothers who answered below the mean of the knowledge assessing questions were considered as having poor knowledge.

| Poor practice
Those mothers who answer below the mean of the practice assessing questions were considered as having poor practice.

| Caregiver
Who directly give care for child and bring to health facility or other else during illness.
F I G U R E 1 Sampling procedure, to assess caregivers' knowledge and practice toward oral rehydration salt with zinc and associated factors to treat diarrhea in under 5 children of Burayu Town, Oromia, Ethiopia, 2022.

| ORS with zinc
A combination of oral rehydration salt and zinc supplement which could available either separately or packed together (two sackets of ORS with 10 tabs of zinc).

| Data collection tools and techniques
Data were collected by using pretested, interviewer-administered structured questionnaires.The questionnaires were developed in English after reviewing of related available literature. 17,19,23,25,26The English version of the questionnaire was translated to regional languages of the community (Afan Oromo and Amharic).The questionnaire had three parts: (sociodemographic characteristics of caregivers, knowledge of caregivers toward ORS with zinc supplementation, and practice of caregivers toward ORS with zinc supplementation to treat diarrhea in under 5 children).Questions on practice were asked only mothers/caregivers whose child ever experience diarrhea.Data were collected by four BSc nurses who were fluent in both Afan Oromo and Amharic languages.During data collection, where more than one under 5 children in the selected household, only one child was selected by lottery method.

| Data quality control and management
First, data collectors were received training before the data collection.The prepared sets of questionnaires were pretested 1 week before data collection on 21 (5% sample size) of under 5 children's mothers/caregivers in Gefersa Burayu Kebele who were not included in the main study; to maintain accuracy and clarity of the questionnaire and to check the consistency in interpretation.
Questionnaires were revised in accordance with the findings of pretesting and all the ambiguous, misleading, and wrongly interpreted questions were omitted.Questions on practice were asked depending on last/recent episode of diarrhea to minimize recall bias.
Questionnaires were also checked daily for completeness, consistency, and clarity by the researcher.In addition, the thesis supervisors (two health officers) and the researcher were also visited the data collection sites periodically to monitor the process of data collection.

| Data processing and analysis
First, the data were checked for completeness and consistency.Then, it was coded, cleaned; and entered by using epi-info software version 3.1 and then, exported to SPSS version 21 for analysis.Descriptive statistics was used to summarize the sociodemographic characteristics of the study participants, level of knowledge, and practice for knowledge and practice.Tables, charts, and graphs were used to present data frequencies and percentages.The level of knowledge and practice were dichotomized as "Good" or "Poor" depending on the mean after the normality of data distribution was checked by histogram.Bivariate and multivariate logistic regression analysis was employed to examine the associations between independent variables and the outcome variables.First, bivariate logistic regression was performed to each independent variable with the outcome variable; and variables with p < 0.25 were made candidate for the multivariable analysis.Multicollinearity was checked by collinearity matrix, tolerance test, and variance inflation factor.Model fitness was also checked with Hosmer-Lemeshow goodness-of-fit test.Multivariate logistic regression analysis was computed to identify associated factors with the knowledge and practice of mothers/ caregivers.Strength of association was measured using adjusted odds ratio, at 95% CIs.Statistical significance was declared at p < 0.05. 3 | RESULTS when compared with mothers who had poor knowledge (Table 5).).This difference may be resulted from differences in sample size or health education given for diarrhea management for the respondents. 17,19e level of practice in the present study is better than the study conducted in Gojjam town, Ethiopia, which indicated 45.9% of the respondents had good practice.The higher practice on diarrhea management with ORS with zinc in present study might be due to difference in study period as awareness on child care service is improving from day-to-day.However, the present result is lower than what was reported from study at conducted at Ginchi town, Ethiopia (52% vs. 59%).The lower practice in present study may be as a result of difference in sample size among the two studies.

| DISCUSSION
Educational status, occupation, marital status, income, and place sought for treatment were significantly associated with caregivers' level of knowledge.Educated mothers/caregivers were more likely to have good knowledge of ORS with zinc when compared with mothers/caregivers with no formal education.As the educational status of mothers/caregivers increases level of knowledge of caregivers about ORS with zinc also increases.This is in line with the study which was conducted in Ginchi town, Ethiopia. 19The fact is that highly educated mothers have higher access to information than that of mothers with no formal education and had lower educational status.
In this study, women whose occupation was housewives were less likely to have good knowledge of ORS with zinc for diarrhea management when compared with employees.This finding is consistent with the finding from the study conducted in Iran which indicated a significant association between occupational status and level of knowledge of child caregivers. 27The reason may be housewives might not have access to information about ORS with zinc in diarrhea management since they are busy with work overloads.
Divorced caregivers were less likely to have good knowledge of ORS with zinc when compared with married caregivers.The reason may be married caregivers might share information with their husbands.
In addition, mother/caregivers with better income were more likely to have good knowledge of ORS with zinc when compared with those with lower income.This finding is consistent with the study done in Serbo town, Ethiopia, which showed mothers with higher income had good knowledge when compared with those having lower income. 23The reason may be those with better income might visit health facilities than caregivers with lower income so that they could get information about ORS with zinc from health facilities or they might access to media or other source of information than those with lower income.
Mother/caregivers who sought treatment at government health facilities were also more likely to have good knowledge of ORS with zinc as compared with who did not visited government health facilities.This is consistent with the study which was conducted in Uganda where mothers/caregivers who visited health centers were more likely to have good knowledge of ORS with zinc when compared with who visited other else.The reason may be due to the fact those who visited government health facilities could heard information about use of ORS with zinc from health care providers and health care providers in government health facilities are access to updated information/training about diarrhea management.
In current study, occupation, educational status, place sought for treatment, and level of knowledge had significant association with practice of mothers/caregivers on ORS with zinc.In this study housewives were less likely to have good practice when compared with employed mothers/caregivers.This finding is similar with the findings from study conducted in Iran which indicated employed mothers had better practice on diarrhea management when compared with housewives. 27The reason may be, employed caregivers are most probably educated and they are access to different source of information about child care than housewives.
Mothers/caregivers who attained secondary school and above were more likely to practice ORS with zinc when compared with mothers/caregivers with no formal education.This is consistent with the study which was conducted in Ginchi, Ethiopia, in Fenote Selam, Ethiopia, in Benishangul, Ethiopia, and in Nigeria which showed level of education increases level of practice of diarrhea management. 17,19,26,28The fact is that highly educated mothers have higher access of information about ORS with zinc and can practice than mothers with no formal education and had lower educational status.
In addition, place sought for treatment/advice were also associated with practice toward ORS with zinc.Mothers/caregivers who visited government health facility/health centers were more likely to have good practice of ORS with zinc when compared with who visited other else.9][30] This might be due to the fact that health care providers in government facility have access to training which contributes to provision up to date information.
This study also revealed that level of knowledge had positively associated with practice of caregivers toward ORS with zinc.
Mothers/caregivers who had good knowledge were more likely to have good practice on ORS with zinc when compared with mothers with poor knowledge.It is similar with the study which was conducted in west Gojjam, Ethiopia, in Debre Birhan, Ethiopia, and in Doba town, Ethiopia, which showed caregivers who had poor knowledge were less likely to have good practice on diarrhea management. 17,30,31The fact is that knowledgeable mothers can easily manage diarrhea than mothers who had poor knowledge.

| Strength of the study
This study was conducted in a community having advantage than institution-based studies.

| Limitations of the study
The main limitation of this study is that it is limited to cross-sectional approach, thus unable to formulate a causal association as to how and when the associations are established.Another limitation of this study is that practice of mothers was assessed alone by asking practice question rather than observing while mothers were demonstrating.The study also used only the quantitative data collection method, but it was better if qualitative methods included like observation.It is possible that some caregivers might not remember the details information which might result in recall bias.In addition, shortage of literatures on knowledge and practice of caregivers' on ORS with zinc in diarrhea management was a challenge during writing this thesis.

| CONCLUSION
Based on findings of the study, the researcher has drawn the following conclusions.The more mothers/caregivers are knowledgeable, the more they are active to practice the use of ORS with Zinc.
This study revealed that 59% of mothers/caregivers have good knowledge and 52% have good practice toward ORS with zinc.
Significant number of mothers/caregivers did not seek any treatment for their children during diarrheal episodes.Educational status, occupation, marital status, place sought for treatment, not taking any treatment action for diarrhea, and income level of child caregivers' had significant association with knowledge of ORS with zinc.Moreover, occupation, educational status, visiting government health facility, and level of knowledge of caregivers had significant association with practice of caregivers on ORS with zinc.For future researchers ❖ Future researcher also needs to explore the effects of additional variables that were not measured in the current study which can influence mothers/caregivers knowledge and practice toward management of diarrhea by ORS with zinc.

RECOMMENDATIONS
❖ In addition, it is better to deal with qualitative research to explore practice-related problems in detail.
Ethical clearance was obtained from the Institutional Review Board of Ambo University, College of Medicine and Health Sciences.Official permission letter was given to the Burayu town Health office.Then Burayu town Health office sent official support letter to selected kebeles.Verbal informed consent from parents/caregivers of under 5 children was obtained and each study participant was adequately informed about the objective of the study and anticipated benefit and risk of the study by their data collectors.Privacy and confidentiality of collected information was ensured at all level.Respondents were also told the right not to respond to the questions if they do not want to respond or to terminate the interview at any time.

For health profession ❖❖❖❖
Health care provider should not simply focus on only dispensing either ORS or zinc; they should also spend more time to emphasize on the need of ORS with zinc for the prevention of dehydration due to diarrhea and advice/demonstrate on how to use ORS or zinc.Activities should also focus as to why, when, and duration it should be used and how correctly it can be used.❖ There should be continuous in depth/strengthened health education and awareness creation for the mothers/caregivers on appropriate use of ORS with zinc in the management of diarrhea For community The community should follow health education given from health professionals to prevent diarrhea and appropriate management of it with ORS and zinc.For Burayu Health Office ❖ Encourage and facilitates health education program with health professionals.Encourage mothers/caregivers to involve in health promotion and prevention of diarrhea & dehydration by collaborating with health professionals.
Among respondents 403 (95.5%) heard about ORS.Among who heard about ORS 337 (83.6%) reported that ORS replaces lost fluid during diarrhea and 58 (14.4%) did not know the role of ORS.Three Sociodemographic characteristics of caregivers of under 5 children in Burayu town, Oromia, Ethiopia, 2022.Knowledge of respondents about ORS with zinc supplementation for diarrhea management in Burayu town, Oromia, Ethiopia, 2022.Factors associated with knowledge of mothers/caregivers of under 5 caregivers toward ORS with zinc in Burayu town, Oromia, Ethiopia, 2022.
A total of 422 respondents participated in the study yielding a response rate of 100%.Of the total participants, 230 (54.5%) were in the age range of 25-34 years with mean (+SD) age of 27.9 ± 5.3 years.More than nine out of 10 (91.9%) of the study participants were married.More than half, 224 (53.1%) of the study participants were Oromo followed by silte 73 (17.3%) ethnic group.(25.4%)employees(government,private,NGOs),merchant65(25.36%).Regarding the educational status of respondents 111(26.3%)hadnoformaleducation,107(25.4%) of them had primary education, and 140 (33.27%)hadabovesecondaryeducation(Table1).DUGUMA ET AL. | 5 of 143.2 | Knowledge of mothers/caregivers about ORS with zinc supplementation severity of diarrhea, while 19 (6.6%) belief that zinc replaces lost fluid with diarrhea and 57 (19.9%) of them did not know the role of zinc in diarrhea management.About 180 (62.7%) also responded that zinc supplement can reduce episode of diarrhea and 118 (41.1%) reported that zinc supplementation during diarrhea increases the appetite ofchildren.Majority 241 (84%) the study subjects know how often zinc should be given, while 136 (47.4%) individuals know the duration zinc should be given.Most of the participants 260 (90.6%) know how to administer zinc for children with diarrhea (Table2).Overall, 243 (59%) of mothers/caregivers had good knowledge of ORS with zinc depending on the mean of 16 questions asked to assess level of knowledge (Figure2).3.3 | Practice of mothers/caregivers toward ORS with zinc in treatment of diarrheaA few of caregivers gave usual food and restrict fluid during diarrheal episode.When asked the reasons why they do not use ORS with zinc: 29 (20.1%)replied they did not know where to obtain it, 56 (38.9%) replied it is not available easily at that time, 59 (41%) mentioned they could not afford it.Majority 153 (55%) of the T A B L E 1 a Grand mother, sister, relative.bWakefata,adventist.cTigre,Dorze, Gamo.(17.7%)replied that they stopped to give zinc as soon as diarrhea stopped.All of the children given zinc supplement once a day and majority 260 (90.6%) of them administered zinc by dissolving in water, milk or in ORS solution.More than half 96 (54.9%) of caregivers did not wash their hands before preparing/dissolving zinc for their children.One hundred seventeen (66.9%) of the children received zinc easily or without difficulty and the rest were given zinc forcefully.In general 52% of child caregivers' have good practice toward ORS with zinc depending on 18 questions asked to assess level of their level of knowledge (Table3).95%CI:[0.195,0.848)lesslikely to have good knowledge of ORS with zinc for diarrhea management when compared with employees.Mothers/caregivers who had secondary education were about 2.8 times (AOR: 2.75, 95% CI:[1.226,6.181])morelikely to have goodT A B L E 2 | 7 of 14 F I G U R E 2Level of knowledge of under 5 caregivers about oral rehydration salt with zinc in Burayu town, Oromia, Ethiopia, 2022.F I G U R E 3 Health seeking behavior of child caregivers on diarrhea management in Burayu town, Oromia, Ethiopia, 2022.mother/caregiversthosesoughttreatment at government health facility (health centers) were about 4 times (AOR: 3.92, 95% CI: [1.77, 8.67]) more likely to have good knowledge of ORS and zinc as compared with those visited elsewhere (Table4).In bivariate logistic analysis, occupation, educational status, sex, marital status, income, level of knowledge, and place sought for treatment were associated with practice of caregivers on ORS with zinc in treatment of diarrhea at p < 0.25 and were included into multivariate logistic regression analysis.at p < 0.05.Housewives were 91.6% times (AOR: 0.084, 95% CI: [0.029, 0.243]) less likely to have good practice when compared with employees.Mothers with beyond secondary education were more than six times (AOR: 6.26, 95% CI: [1.51, 25.86]) more likely to have good practice when compared with those had no formal education.Mothers/caregivers who visited government health facility (health centers) were about seven times T A B L E 4 (AOR: 6.885, 95% CI: [2.29, 20.67]) more likely to have good practice of ORS with zinc when compared with who visited elsewhere.Mothers/ caregivers who had good knowledge were about 22 times (AOR: 22.14, 95% CI: [8.44, 58.07]) more likely to have good practice of ORS with zinc Factors associated with practice of mothers/caregivers of under 5 children toward ORS with zinc in Burayu town, Oromia, Ethiopia, 2022.
This study aimed to assess knowledge, practice and associated factors toward ORS with zinc among under 5 caregivers/mothers of Burayu town.The study revealed that 249 (59%) and 167 (52%) of T A B L E 5